Trauma/Sepsis/MODS/Burns NCLEX questions 2020

It is suspected that a patient is developing SIRS. Which assessment findings would the nurse interpret as supporting this suspicion? (Select all that apply.) 1. PaCO2 38 mm Hg 2. Heart rate 108/min 3. WBC 10,000/mm3 4. Respiratory rate 22/min 5. Temperature of 96.4°F (35.8°C)

Answer: 1, 2, 4, 5 Rationales:. 1. The PaCO2 of 38mm Hg is WNL 2.Tachycardia of over 90 beats/min is a criterion for the diagnosis of SIRS. 3. WBC greater than 12,000/mm3, less than 4,000/mm3, or greater than 10% immature (band) forms is a criterion for the diagnosis of SIRS. 4. A respiratory rate over 20/min is a criterion for the diagnosis of SIRS. 5. A core temperature higher than 38°C (100.9°F) or lower than 36°C (96.8°F) is a criterion for the diagnosis of SIRS.

Which assessment would alert the nurse to the presence of a flail chest? 1. Tachycardia 2. Paradoxical chest wall movement 3. Splinting 4. Tachypnea

Answer: 2 Rationales: 1. Tachycardia is related to numerous patient situations and is not specific to flail chest. 2. Paradoxical chest wall movement occurs when a section of the chest wall is no longer attached to the underlying rib structure. This section "floats" and moves in an opposite direction from the remainder of the chest wall. When the chest wall expands, this section retracts. This is a classic finding associated with flail chest. 3. Splinting is related to any painful movement and is not specific to flail chest. 4. Tachypnea is related to numerous patient situations and is not specific to flail chest.

A patient in septic shock has been prescribed a vasopressor medication. Which assessment finding would the nurse evaluate as indicating the need to question this order? 1. The patient's heart rate is 50 bpm. 2. The patient's urine output for the last hour was 10 mL. 3. The patient's breath sounds include crackles. 4. The patient's mentation has not improved.

Answer: 2 Rationales: 1. The low heart rate may relate to the shock state. It is not a reason to question the order. 2. Vasopressor medications are not effective if there is inadequate circulating blood volume. Poor urine output is one measure of insufficient fluid resuscitation. 3. Crackles in the lungs indicate potential fluid overload. The use of vasopressor medications may reduce the amount of IV fluid needed to support the patient's perfusion. 4. The patient's mentation has not improved because the shock state continues. This is not a reason to question the order.

A patient who was admitted to the emergency department after a gunshot wound to the chest is hemorrhaging. What interventions should the nurse anticipate? (Select all that apply.) 1. Administration of IV vasopressors 2. Initiation of IV access with two large-bore catheters 3. Open resuscitative thoracotomy 4. Administration of packed red blood cells 5. Rapid administration of IV fluid

Answer: 2, 3, 4, 5 Rationales: 1. IV vasopressors will not be administered until fluid resuscitation is achieved. 2. IV access should be achieved with large-bore catheters to allow for rapid administration of blood or fluid. 3. Open resuscitative thoracotomy may be done as a last resort to manage the bleeding structures within the chest. 4. Blood and blood products will be administered to increase oxygen-carrying capacity. 5. Intravascular fluid volume must be replaced. IV fluids are easily obtainable and can be administered quickly.

A nurse is advised that a patient with multiple blunt trauma is expected to arrive in the emergency department. What preparations should the nurse make? 1. Check the available supply of dressings and bandages. 2. Stock the receiving room with suture kits. 3. Prepare a chest tube drainage tray. 4. Alert radiology staff that x-rays will be required.

Answer: 4 Rationales: 1. Dressings and bandages are not the priority because skin integrity is not disturbed in blunt trauma. 2. Blunt trauma is defined as an injury in which the skin integrity is not disturbed. If this patient's injuries are limited to blunt trauma, suture kits will not be required. 3. A chest tube drainage tray may be required, but it is not clear if that is the case in this situation. 4. Because the forces of blunt trauma are transferred to the tissues involved, deformation is likely. Radiologic studies are necessary to determine the presence of broken bones and other injuries.

A patient has hypovolemic shock as a result of massive gastrointestinal bleeding. The patient is given fluids and vasopressors. Which outcome indicates to the nurse that these treatments are having the desired effect? 1. Urine output is normal. 2. Base deficit is -6 mmol. 3. Blood pressure is now 90/60 mm Hg. 4. Lactate levels are decreasing from admission levels.

Answer: 4 Rationales: 1. Using urine output as a marker of resuscitation may provide a false sense of security because the urine output may be related to neuroendocrine response. 2. A base deficit of -6 mmol indicates that moderate shock is persisting. 3. Shock can persist despite "normalization" of blood pressure. This BP may be normal for one patient and hypotensive for another. 4. Serum lactate levels can be used as an indirect measure of impaired oxygen delivery and indicate the degree of hypoperfusion. Decreasing lactate levels indicate that tissue perfusion and oxygenation are improving.

A patient has an open pneumothorax. Which nursing actions are indicated? Select all that apply. 1.place an occlusive dressing over the wound 2.Leave the bottom of the dressing untaped 3.Cover the area with a light covering of sterile gauze 4. Pack the wound with saline-soaked gauze

Correct 1.Place an occlusive dressing over the wound 2.Leave the bottom of the dressing untapped Rationale An occlusive dressing will restrict the amount of free air entering the chest cavity. Leaving the bottom of the dressing untaped allows air to escape from the chest cavity if pressure increases.

To position a client's burned upper extremities appropriately, how does the nurse position the client's elbow? 1. in a neutral positon 2. in a position of comfort 3. sightly flexed 4. Slightly hyperextended

Correct: 1 In a neutral position The neutral (extended) position is the correct placement of the elbow to prevent contracture development.Placing the elbow in a position of comfort is not the best placement because the client then usually wants to flex the joint, which increases the risk for contracture development. The slightly flexed position increases the risk for contracture development. The slightly hyperextended position is not indicated and can be painful.

The nurse reviews the medical record of a client with hemorrhagic shock, which contains the following information:Physical Assessment FindingsDiagnostic FindingsPulse 140 beats/min and threadyABG respiratory acidosisBlood pressure 60/40 mm HgLactate level 63 mg/dL(7 mmol/L)Respirations 40/min and shallowAll of these provider prescriptions are given for the client. Which does the nurse carry out first? 1. notify anesthesia for endotracheal intubation 2. Give plasmanate 1 unit now 3. Give normal saline solution 250mL/hr 4.type and crossmatch for 4 units of PRBC's

Correct: 1 The nurse must first notify anesthesia for endotracheal intubation for this client with hemorrhagic shock. Establishing an airway is the priority in all emergency situations.Although administering Plasmanate and normal saline, and typing and cross matching for 4 units of PRBCs are important actions, airway always takes priority.

A rock climber has sustained an open fracture of the right tibia after a 20-foot (6 meter) fall. The nurse plans to assess the client for which potential complications?SATA 1. Acute compartment syndrome 2.Fat embolism 3.Congestive heart failure 4. urinary tract infection 5. osteomyelitis

Correct: 1,2,5 ACS is a serious condition in which increased pressure within one or more compartments reduces circulation to the area. A fat embolus is a serious complication in which fat globules are released from yellow bone marrow into the bloodstream within 12 to 48 hours after the injury. FES usually results from long bone fracture or fracture repair but is occasionally seen in clients who have received a total joint replacement. Bone infection, or osteomyelitis, is most common in open fractures.Congestive heart failure is not a potential complication for this client; pulmonary embolism is a potential complication of venous thromboembolism, which can occur with fracture. The client is at risk for wound infection resulting from orthopedic trauma, not a UTI.

The nurse admits an older adult client who sustained a left hip fracture and is in considerable pain. The nurse anticipates that the client will be placed in which type of traction prior to surgical repair? 1. Balanced skin traction 2. Bucks traction 3. Overhead traction 4. Plaster traction

Correct: 2 Buck's tractionBuck's traction may be applied before surgery to help decrease pain associated with muscle spasm.Balanced skin traction is indicated for fracture of the femur or pelvis. Overhead traction is indicated for fracture of the humerus with or without involvement of the shoulder and clavicle. Plaster traction is indicated for wrist fracture.

Emergency Medical Services arrives at the scene of an automobile crash. On primary assessment, the driver is found to be unresponsive, not breathing, and has a grossly deformed left leg with no pulse. What is the first resuscitation intervention to be performed? 1. Carry out artificial respirations 2. Clear the airway 3. Place a cervical collar 4. Realign the leg and check for pulse

Correct: 2 Clear the airway. The airway should first be cleared of any secretions or debris with a suction catheter or manually, if necessary. The primary survey for a trauma client is based on the mnemonic "ABCDE", with "A" being airway.A cervical collar will need to be applied and respiration will need to be assisted with a bag-valve-mask (BVM) connected to 100% oxygen source. Although the leg does not have a pulse, life threats must be addressed before limb threats.

Which clinical symptoms in a postoperative client indicate early sepsis with an excellent recovery rate if treated? 1.localized erythema and edema 2.low grade fever and mild hypotension 3. low oxygen saturation and decreased cognition 3.Reduced urinary output and increased respiratory rate

Correct: 2 Low-grade fever and mild hypotension in a postoperative client indicate very early sepsis. With treatment, the probability of recovery is high.Localized erythema and edema indicate local infection. A low oxygen saturation rate and decreased cognition indicate severe sepsis. Reduced urinary output and increased respiratory rate indicate active (not early) sepsis.

A client arrives at the emergency department who suffered multiple injuries from a head-on car collision. Which of the following assessment should take the highest priority to take? 1.irregular pulse 2.Ecchymosis in the flank area 3.deviated trachea 4.unequal pupils

Correct: 3 A deviated trachea is a symptom of tension pneumothorax, which will result in respiratory distress if left untreated

A client was brought to the emergency department after suffering a closed head injury and lacerations around the face due to a hit-run accident. The client is unconscious and has minimal response to noxious stimuli. Which of the following assessment findings if observed after few hours, should be reported to the physician immediately? 1.Bleeding around the lacerations 2.Withdrawal of the client in response to painful stimuli 3.Bruises and minimal edema of the eyelids 4.drainage of a clear fluid from the clients nose

Correct: 4 Clear drainage from the client's nose indicates that there is a leakage of CSF and should be reported to the physician immediately

A client is admitted to the emergency department after being in a motor vehicle crash. The client was wearing a seat belt and the airbag deployed. There are no apparent injuries besides an abrasion from the shoulder harness across the clavicle and anterior chest. First vital signs are BP 110/70, HR 98, R 18, SaO2 98% on room air. The client's Glasgow Coma Scale score is 15. What does the nurse do next? 1. allow the client to go home 2. Check blood alcohol levels 3. prepare the client for surgery 4. monitor the client

Correct: 4 Monitors the client Blunt force injuries are from acceleration/deceleration forces, and can cause trauma to bones, blood vessels, and soft tissue. An injury may not be evident right away. A seat belt abrasion across the chest would alert the nurse to monitor closely for signs of potential internal injuries.While the nurse is monitoring the client, routine labs, including blood alcohol levels, may be obtained as well as computerized tomography (CT) scans. Based on these results, a decision regarding disposition will be made. Allowing the client to go home or preparing for surgery are not appropriate actions in this situation

The nurse performs a neurovascular assessment on a client with closed multiple fractures of the right humerus who is experiencing increased pain even with maximum ordered doses of morphine. The nurse notes distal capillary refill of 3 seconds and coolness of the hand and fingers. The client reports numbness of the hand and is unable to wiggle the thumb. Which nursing action is indicated? 1. elevate the extremity 2. apply an ice pack to the extremity 3. reposition the extremity and recheck in 15-20 min 4. Notify the provider of these findings

Correct: 4 Notify the provider of these findings. Pain unrelieved by narcotic analgesics and numbness of the affected extremity are signs of neurovascular compromise and should be reported immediately to the provider.Elevating the extremity and applying ice may further compromise blood flow and should be avoided. Compartment syndrome may develop quickly, so the provider should be notified immediately and not in 15 to 20 minutes.

A client is in the acute phase of burn injury. For which action does the nurse decide to coordinate with the registered dietitian? 1.Discouraging having food brought in from the client's favorite restaurant 2.Providing more palatable choices for the client 3.Helping the client maintain a desirable weight 4.Planning additions to the standard nutritional pattern

Correct: 4 Planning additions to the standard nutritional pattern Consultation with the dietitian is required to help the client achieve the correct nutritional balance. Nutritional requirements for the client with a large burn area can exceed 5000 kcal/day. In addition to a high calorie intake, the burn client requires a diet high in protein for wound healing.It is fine for the client with a burn injury to have food brought in from the outside. The hospital kitchen can be consulted to see what other food options may be available to the client. It is not therapeutic for the client with burn injury to lose weight.

The client is a burn victim who is noted to have increasing edema and decreased urine output as a result of the inflammatory compensation response. What does the nurse do first? 1. administer a diuretic 2. provide a fluid bolus 3. recalculate fluid replacement based on time of hospital arrival 4. titrate fluid replacement

Correct: 4 Titrate fluid replacement. The nurse first needs to adjust and titrate the intravenous fluid rate on the basis of urine output plus serum electrolyte values.A common mistake in treatment is giving diuretics to increase urine output. Giving a diuretic will actually decrease circulating volume and cardiac output by pulling fluid from the circulating blood volume to enhance diuresis. Fluid boluses are avoided because they increase capillary pressure and worsen edema. Fluid replacement formulas are calculated from the time of injury, not from the time of arrival at the hospital.

Which information about a client who was admitted with a pelvic fracture after being crushed by a tractor is most important for the nurse to assess to monitor for serious complications from this type of injury? 1.skin ti evaluate lacerations and abrasions 2.lungs for bilateral normal breath sounds 3.pain score and level of alertness 4.urine dipstick for the presence of red blood cells

Correct: 4 Urine dipstick for the presence of red blood cells. It is most important for the nurse to monitor for the presence of blood in the urine as well as assessing the abdomen for rigidity. Clients with crushing injuries to the pelvis are at increased risk of internal hemorrhage. Pelvic injuries are the second cause of death from trauma after head injuries.Assessing the skin for external trauma and monitoring pain and alertness will be performed as part of the overall assessment but are not critical nursing actions at this time. Assessing lung sounds is more critical with chest injuries and rib fractures.

Which clients are at immediate risk for hypovolemic shock? SATA 1. unrestrained client in a motor vehicle collision (MVC) 2. construction worker 3. athlete 4. surgical intensive care unit (SICU) client 5. 85-year-old with a GI virus

Correct:1,4,5 Clients who are immediate risk for hypovolemic shock include: the unrestrained client in a (MVC), the SICU client, and the 85-year-old client with GI virus. The client who is unrestrained in a MVC is prone to multiple trauma and bleeding. Surgical clients are at high risk for hypovolemic shock owing to fluid loss and hemorrhage. Older adult clients are prone to shock, especially if a gastrointestinal virus is present that results in fluid losses.Unless injured or working in excessive heat, the construction worker and the athlete are not at risk for hypovolemic shock. They may, however, be at risk for dehydration.

. A patient is received in the emergency department from emergency medical services after sustaining a brain injury in a fall. She is on a backboard and has a cervical collar in place. She is not moving her lower extremities. What would alert the nurse to the possible development of neurogenic shock? 1. The patient's blood glucose is 134 mg/dL. 2. The patient reports that she feels a tingling sensation in her lower extremities. 3. The patient's friend reports that the patient was unconscious for a "few seconds" after the fall. 4. The patient's heart rate drops from 82 bpm to 68 bpm.

Correct:4 Rationales 1. Elevation of blood glucose could be attributed to several factors and is not specifically associated with the development of neurogenic shock. 2. The change to a tingling sensation could be attributed to many factors. This is not the finding associated with neurogenic shock. 3. While a period of unconsciousness is a significant finding, it is not the finding that would alert the nurse to the potential for neurogenic shock. 4. Bradycardia is an indicator that shock is developing. This patient's heart rate is dropping, and the nurse should be aware of the potential for developing shock.

A patient presents to the Emergency Department with a branch impaled in his arm. What nursing actions are indicated? Select all that apply. 1.Prevent the patient from removing the object. 2.Remove the branch with slow, steady pressure. 3.Remove the branch quickly. 4.Stabilize the object with padding.

answers: 1.Prevent patient from removing the object 4.stabilizing the object with padding Rationale The patient may attempt to remove the impaled object. The nurse should prevent this from occurring. The object should be stabilized with padding until further examination

A client sustains a fracture of one arm and the provider applies a plaster cast to the extremity. What will the nurse teach the client to do during the first 24 hours after discharge from the emergency department? 1. Monitor neuromuscular status for decreased circulation and sensation in the extremity 2.apply a heating pad for 15-20 min four times daily to help with pain 3. Check the fit of the cast by inserting a tongue blade between cast and skin 4. Keep the cast covered with a soft towel to help it to dry quickly

correct :1 Monitor neuromuscular status for decreased circulation and sensation in the extremity.The most important intervention the nurse teaches the client is to monitor the neurovascular status during the first 24 hours after ED discharge.The client should apply ice for discomfort, not heat. The client should not place anything between the cast and the skin. In assessing fit, one finger should easily fit between the cast and the skin. To allow the cast to dry, it should remain uncovered.

A client with an open fracture of the left femur is admitted to the emergency department after a motorcycle crash. Which action is most essential for the nurse to take first? 1. Check the dorsalis pedis pulses 2. immobilize the left leg with a splint 3. administer the prescribed analgesic 4.Place a dressing on the affected area

correct: 1 Check the dorsalis pedis pulses. The most essential action should be to check the dorsalis pedis pulses. It is necessary to assess the circulatory status of the leg because the client is at risk for acute compartment syndrome, which can begin as early as 6 to 8 hours after an injury. Severe tissue damage can also occur if neurovascular status is compromised.Immobilization will be needed, but the nurse must assess the client's condition first. Administering an analgesic and placing a dressing on the affected area would both be done after the nurse has assessed the client.

A client with partial-thickness burns of the face and chest caused by a campfire is admitted to the burn unit. The nurse plans to carry out which health care provider request first? 1.Give oxygen per face mask 2.infuse LR solution at 150 mL/hr 3. Give morphine sulfate 4-10 mg IV for pain control 4. insert a 14 Fr retention catheter

correct: 1 Give oxygen per facemask. The nurse needs to first administer oxygen per face mask to the client. Facial burns are frequently associated with upper airway inflammation. Administration of oxygen will assist in maintaining the client's tissue oxygenation at an optimal level.Although fluid hydration and pain control are important, the nurse's first priority is the client's airway. Monitoring output is important, but the nurse's first priority is the client's airway.

A newly admitted client has deep partial-thickness burns. The nurse expects to see which clinical manifestations? 1.Red and white wounds with mild pain to palpation 2.Painless, brownish yellow eschar 3.Painful reddened blisters 4.Black skin with eschar and no pain

correct: 1 Red and white wounds with mild pain to palpation A red and white wound bed characterizes deep partial-thickness burns. Blisters are rare. Pain is less than with other types of burns because nerve endings are affected.Painless, brownish yellow eschar characterizes a full-thickness burn. A painful reddened blister is seen with a superficial partial-thickness burn. Painless black skin with eschar is seen in a deep full-thickness burn.

A client is admitted to the hospital with two of the systemic inflammatory response syndrome variables: temperature of 95°F (35°C) and high white blood cell count. Which intervention from the sepsis resuscitation bundle does the nurse initiate? 1. Broad-spectrum antibitocs 2. Blood transfusion 3. cooling baths 4. NPO status

correct: 1. Broad-spectrum antibiotics From the sepsis resuscitation bundle the nurse initiates broad-spectrum antibiotics within 1 hour of establishing diagnosis.A blood transfusion is indicated for low red blood cell count or low hemoglobin and hematocrit. Transfusion is not part of the sepsis resuscitation bundle. Cooling baths neither are indicated because the client is hypothermic nor are this part of the sepsis resuscitation bundle. NPO status neither is indicated for this client nor is it part of the sepsis resuscitation bundle.

The nurse plans to administer an antibiotic to a client newly admitted with septic shock. What action does the nurse take first? 1. administer the antibiotic immediately 2. ensure that blood cultures were drawn 3. obtain signature for informed consent 4. take the clients vital signs

correct: 2 Ensure that blood cultures were drawn. The nurse's first action when planning to administer an antibiotic to a newly admitted patent in septic shock is to ensure that blood cultures were drawn. Cultures must be taken to identify the organism for more targeted antibiotic treatment before antibiotics are administered. Antibiotics are not administered until after all cultures are taken.A signed consent is not needed for medication administration. Monitoring the client's vital signs is important, but the antibiotic must be administered within 1 to 3 hours, because timing is essential.

A client is in the resuscitation phase of burn injury. Which route does the nurse use to administer pain medication to the client? 1. IM 2.IV 3.Sublingual 4.Topical

correct: 2 Intravenous During the resuscitation phase, the intravenous (IV) route is used for giving opioid drugs because of problems with absorption from the muscle and stomach.When these agents (opioid drugs) are given by the intramuscular or subcutaneous route, they remain in the tissue spaces and do not relieve pain. In addition, when edema is present, all doses are rapidly absorbed at once when the fluid shift is resolving. This delayed absorption can result in lethal blood levels of analgesics. The sublingual route may not be effective, and because the skin is too damaged, the topical route is not indicated for administering drugs to the client in the resuscitation phase of burn injury.

How does the nurse caring for a client with septic shock recognize that severe tissue hypoxia is present? 1.PaCO2 58 mm Hg 2. Lactate 81 mg/dK (9.0mmol/L) 3. PTT 64 seconds 4. potassium 2.8 mEq/L(2.8 mmol/L)

correct: 2 Lactate 81 mg/dL (9.0 mmol/L) The client with septic shock and a lactate level of 81 mg/dL (0.9 mmoL/L) indicates that severe tissue hypoxia is present. Poor tissue oxygenation at the cellular level causes anaerobic metabolism, with the by-product of lactic acid.Elevated partial pressure of carbon dioxide occurs with hypoventilation, which may be related to respiratory muscle fatigue, secretions, and causes other than hypoxia. Coagulation times reflect the ability of the blood to clot, not oxygenation at the cellular level. Elevation in potassium appears in septic shock due to acidosis, but this value is decreased and is not consistent with septic shock.

Which wound assessment characteristics suggest a superficial partial-thickness burn injury? 1. black- brown coloration 2. painful blisters 3. moderate to severe edema 4. absence of blisters

correct: 2 Painful blisters Characteristics of a superficial partial-thickness burn injury include pink to red coloration, mild to moderate edema, pain, and blisters.A black-brown coloration is more suggestive of full-thickness burn injury. Moderate to severe edema and absence of blisters may be present with deep partial-thickness to full-thickness burn injuries.

A client with burn injuries is admitted. Which priority does the nurse anticipate within the first 24 hours? 1. ROM exercises 2. Emotional support 3.fluid resuscitation 4.sterile dressing changes

correct: 3 Fluid resuscitation During the first 24 hours after a burn injury, the nurse's first priority is to administer fluid resuscitation because fluid does not stay in the vessels after a burn injury.Range-of-motion exercise is not the priority for this client. Although emotional support and sterile dressing changes are important, they are not the priority during the resuscitation phase of burn injury.

In assessing a client in the rehabilitative phase of burn therapy, which priority problem does the nurse anticipate? 1.intense pain 2. potential for inadequate oxygenation 3.impaired self-image 4.potential for infection

correct: 3 Impaired self-image A priority problem of impaired self-image is expected during the rehabilitation phase. During this phase, the client is discharged and his or her life is not the same.A priority problem of impaired self-image is expected. Intense pain and potential for inadequate oxygenation are relevant in the resuscitation phase of burn injury. Potential for infection is relevant in the acute phase of burn injury.

Which assessment is the nurse's highest priority in caring for a client in the acute phase of burn injury? 1. bowel sounds 2.muscle strength 3. signs of infection 4.urine output

correct: 3 Signs of infection The client with burn injury is at highest risk for infection as a result of open wounds and reduced immune function. Burn wound sepsis is a serious complication of burn injury, and infection is the leading cause of death during the acute phase of recovery.Assessing bowel sounds, assessing muscle strength, and assessing urine output are important but not the priority during the acute phase of burn injury.

Which assessment information about a 60-kg client admitted 12 hours ago with a full-thickness burn over 30% of the total body surface area is of greatest concern to the nurse? 1.bowel sounds are absent 2. the pulse oximetry level is 91% 3. The serum potassium level is 6.1 mEq 4.the urine output since admission is 370 mL

correct: 3 The serum potassium level is 6.1 mEq/L (6.1 mmol/L). The greatest concern for the nurse is to notice an elevated serum potassium level that can cause cardiac dysrhythmias and arrest.Absence of bowel sounds, a pulse oximetry level of 91%, and urine output of 370 mL since admission are normal findings during the resuscitation phase of burn injury.

The nurse is evaluating the effectiveness of fluid resuscitation for a client in the resuscitation phase of burn injury. Which finding does the nurse correlate with clinical improvement? 1.Blood urea nitrogen (BUN), 36 mg/dL (12.9 mmol 2.Creatinine, 2.8 mg/dL (248 mcmol/L) 3.Urine output, 40 mL/hr Urine specific gravity, 1.042

correct: 3 Urine output, 40 mL/hr Clinical improvement based on fluid resuscitation for a burn client correlates with a urine output of between 30 and 50 mL/hr or 0.5 mL/kg/hr.A BUN of 36 mg/dL (12.9 mmol/L) is above normal, a creatinine of 2.8 mg/dL (248 mcmol/L) is above normal, and a urine specific gravity of 1.042 is above normal.